Attributable Mortality of Ventilator-associated Pneumonia Among Patients with COVID-19

Abstract

Rationale Patients with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are at higher risk of ventilator-associated pneumonia (VAP) and may have an increased attributable mortality (increased or decreased risk of death if VAP occurs in a patient) and attributable fraction (proportion of deaths that are attributable to an exposure) of VAP-related mortality compared with subjects without coronavirus disease (COVID-19). Objectives Estimation of the attributable mortality of the VAP among patients with COVID-19. Methods Using the REA-REZO surveillance network, three groups of adult medical ICU patients were computed: control group (patients admitted between 2016 and 2019; prepandemic patients), pandemic COVID-19 group (PandeCOV + ), and pandemic non–COVID-19 group (PandeCOV − ) admitted during 2020. The primary outcome was the estimation of attributable mortality and attributable fraction related to VAP in these patients. Using multistate modeling with causal inference, the outcomes related to VAP were also evaluated. Measurements and Main Results A total of 64,816 patients were included in the control group, 7,442 in the PandeCOV − group, and 1,687 in the PandeCOV + group. The incidence of VAP was 14.2 (95% confidence interval [CI], 13.9 to 14.6), 18.3 (95% CI, 17.3 to 19.4), and 31.9 (95% CI, 29.8 to 34.2) per 1,000 ventilation-days in each group, respectively. Attributable mortality at 90 days was 3.15% (95%, CI, 2.04% to 3.43%), 2.91% (95% CI, −0.21% to 5.02%), and 8.13% (95% CI, 3.54% to 12.24%), and attributable fraction of mortality at 90 days was 1.22% (95% CI, 0.83 to 1.63), 1.42% (95% CI, −0.11% to 2.61%), and 9.17% (95% CI, 3.54% to 12.24%) for the control, PandeCOV − , and PandeCOV + groups, respectively. Except for the higher risk of developing VAP, the PandeCOV − group shared similar VAP characteristics with the control group. PandeCOV + patients were at lower risk of death without VAP (hazard ratio, 0.62; 95% CI, 0.52 to 0.74) than the control group. Conclusions VAP-attributable mortality was higher for patients with COVID-19, with more than 9% of the overall mortality related to VAP.

Relationship between corticosteroid use and incidence of ventilator-associated pneumonia in COVID-19 patients: a retrospective multicenter study

“…In COVID-19 patients, VAP is a serious complication, as our group and others demonstrated a significant association between VAP and mortality in this population [25,26]. To date, there is no prospective interventional study that evaluated the impact of corticosteroid use on the incidence of VAP, as the RECOVERY study itself did not include it as an outcome.…”

A machine learning approach identifies unresolving secondary pneumonia as a contributor to mortality in patients with severe pneumonia, including COVID-19

“…32 We and others have reported unexpectedly high rates of VAP complicating the ICU course of patients with SARS-CoV-2 pneumonia. 2,9 Accordingly, we conceptualized a model in which the discordance between ICU LOS and mortality in patients with severe SARS-CoV-2 pneumonia results from a low mortality attributable to the primary viral pneumonia that is offset by an increased risk of mortality from unresolving VAP or other ICU complications.…”

“…4–6,8 These findings support a paradigm in which a relatively low mortality directly attributable to primary SARS-CoV-2 infection is offset by an increased risk of death attributable to unresolving secondary bacterial pneumonia. 9…”

“…[4][5][6]8 These findings support a paradigm in which a relatively low mortality directly attributable to primary SARS-CoV-2 infection is offset by an increased risk of death attributable to unresolving secondary bacterial pneumonia. 9 Testing the hypothesis that unresolving secondary bacterial pneumonia explains the apparent disconnect between LOS and mortality in patients with severe SARS-CoV-2 pneumonia poses two challenges. First, traditional methods to compare ICU outcomes standardize severity of illness on ICU admission and treat the entirety of the ensuing ICU stay as a singular event, neglecting the effect and timing of ICU complications that develop or therapies that are administered during the ICU stay on outcomes.…”

Relationship between corticosteroid administration and incidence of ventilator-associated lower respiratory tract infections in COVID-19 patients: a retrospective multicenter study

“…VA-LRTI in COVID-19 patients is a serious issue, as our group and others demonstrated a signi cant association between VA-LRTI and mortality in this population [24,25]. However, to date there is no prospective interventional study that evaluated the impact of corticosteroid exposure on the incidence of VA-LRTI as the RECOVERY study itself did not include it as an outcome.…”